Diagnostics and Constraints Theory

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Diagnostics and Constraints Theory

• Marcus Kennedy
• Clinical Lead
• Patient Flow Collaborative
• 4th May

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From project to habit

• Themes of today
• Reinforcing what we have learnt
• Showcasing improvements
• Making these effective methods part of every day
  business

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A story

• Hospital x identified an elective surgical
  throughput value stream
• Access problems
• Waiting list blow outs
• Admission systems chaotic
• Theatre bookings whimsical
• Not meeting targets
• Losing bonus dollars
• Losing surgeons

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HELP !!!

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PFC
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Why Multidimensional?

• Because this was the NHS way?
• Because Jenny Bartlett said so?
• Because this way we could see and appreciate
  whole systems from all perspectives
• Organisational
• Patient
• Workers
• To avoid tunnel vision and myths

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Theory of Constraints

• like a chain with its weakest link, in any
  complex system at any point in time, there is
  most often only one aspect of that system that is
  limiting its ability to achieve more of its goal.
  For that system to attain any significant
  improvement, that constraint must be identified
  and the whole system must be managed with it in
  mind

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The Five Focusing Steps of the Theory of
Constraints (TOC)

• Identify the system constraint.
• Although a system will have many processes, few
  will represent a constraint to the overall
  system. The more complex the system, the more
  likely it is that there will be a single, overall
  bottleneck
• Get the most out of the constraint
• since it determines system throughput. The entire
  value of the system is represented by what flows
  through the bottleneck. For instance, you would
  want to keep the bottleneck working all the time,
  since your whole system is idle if the bottleneck
  is idle
• Support the constraint
• by making it only do work that cannot be done
  elsewhere
• Elevate it
• within the system so that all other parts work to
  help it
• Return to step 1
• because a different process may have become the
  constraint

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Constraint Theory
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Hospital x Identified Constraints

1. Discharge incoordination due to registrar OR
   commitments
2. Booking system organisation
3. Availability of fluoroscopy in OR

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Lean approach

• Understand Customers and what they value
• Define the internal value stream
• Eliminate waste, make information products
  flow, pulled by customer needs
• Extend the definition of value outside your own
  company
• Continually aim for perfection

Terry Young, Sally Brailsford, Con Connell, Ruth
Davies, Paul Harper and Jonathan H Klein, Using
industrial processes to improve patient care BMJ
2004328162-164
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Understanding the wastes of lean

• Overproduction
• Producing too much too soon, resulting in poor
  flow of information or the deliverable and excess
  
• Defects
• Frequent errors in paperwork, data and
  information, product quality problems, or poor
  delivery performance
• Unnecessary information or inventory
• Excessive storage and delay of information or
  products, resulting in excessive cost and poor
  customer service
• Inappropriate processing
• Going about work processes with the wrong set of
  tools, procedures of systems, often when a
  simpler approach would have been more effective
• Excessive transportation
• Excessive movement of people, information or
  material, resulting in poor flow and long lead
  times
• Waiting
• Long periods of inactivity for people,
  information or material, resulting in poor flow
  and long lead times
• Unnecessary motion
• Poor workplace organization, resulting in poor
  ergonomics, eg excessive bending or stretching
  and frequently lost items

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Im a textbook hero !
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Solution to key constraint

• Event driven discharge
• Patients went home .6 days earlier
• Capacity improved
• Therefore inspired by sweet success the team
  moved on and tackled the second constraint
• Booking system organisation

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Booking system improvements

• Streamlined
• Removed duplication
• Single assessments
• Removed paperwork
• Automated messaging and contacts / reminders

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Impact -2730 C
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Why is it so?
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Shifting Constraints

• Now that event driven discharge allowed shorter
  LOS
• Allied health services required on the day of
  discharge were unable to meet demands

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Systems are dynamic beasts
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Initial constraint analysis
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Complex Systems

• We deal with complex, multiply intersecting and
  interdependent systems
• Not linear independent production lines

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Chaos Theory

• The relationships within these chaotic systems
  are not always initially clear
• Beware of assumptions (aka myths
  preconceptions) these are the inherent flaws of
  many of our less effective previous strategies
• Continuous measurement and analysis
• Continuous Whole system orientation

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Repeat analysis

• Repeat diagnostics / constraint analysis
• Tailor
• Refine
• Embed methodology
• Actively revisit Lean Methodology interventions
• Targeted at constraints
• Beware fanatical / untargeted application in a
  complex / chaotic system
• Intervention theme not a new organisational
  religion

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Project to System

• Do something or nothing will happen
• Current bed management PFC way to go
• Executive links
• Redefine TOR
• Actively build in Constraint Theory Lean
  Thinking
• Celebrate achievements

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Data

• Selected (refined) data presentation of previous
  month and week
• Forecast data presentation for next week (based
  on historical/previous yr data and known current
  activity threats)

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Strategy

• Current Flow Improvement Strategies (presented in
  action table)
• achievements since last meeting
• challenges encountered in progressing plan
• known threats for next week
• plans for next week
• actions points

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Policy and Procedure

• review of flow policy and process breaches over
  the last week
• actions defined

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Retain Methodological Context

• Review of Constraint Table (Fortnightly)
• Lists Organisational Value Streams, with
  identified key constraints per stream and action
  priorities.
• Identifies next actions re improvement and allows
  forward planning of implementations.
• Drives knowledge of constraint theory and lean
  thinking methodologies

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Anticipation

• Review of Threats (Monthly)
• The month ahead is assessed with regard to
  perceived threats to patient flow eg public
  holidays, staff changeovers, public events,
  conferences and other leave, known infrastructure
  changes, shutdowns or decrease in performance.

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New Hospital Access Targets

• Tens of Million
• Matters to the base budget
• Achievement
• Go harder and faster
• Do something different
• Those that have already implemented change are
  advantaged

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• 12 months down the track
• Are expectations (culture) of flow different?
• Are systems changing to achieve this?
• Have we achieved all we needed to?
• Have we got the right tools?
• Have we learnt to use them optimally?
• Will we get there?

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• Questions

?